Measuring Our Safety-ness By David Carr Director of Safety

APRIL 2013

Measuring our

Safety-ness

A Wire Reminder

From Hero to Zero in

.25 Seconds

Reporting WX Incidents

2013 Incident Stats

Recent Incident Summaries

When I first arrived here in February, I was curious to find

out how a company as decentralized as ours was able to

maintain control of day to day operationsoperational control in aviation parlance. My previous two safety jobs had been with companies who had all their employees and

equipment located in one geographical area. It was easy

to reach out and touch whatever needed attention.

What I found out during my first dizzying month here is

that control of our day to day operations is tied to the

guiding philosophy and the reason your base is a Med-

Trans base. That is, we all fit into the same general

culture. That doesnt mean were all the same, what it means is that we all have our priorities and values aligned.

When I first started out in commercial aviation safety, my

new boss asked me, how do we measure how safe we are? That took me by surprise. In the military, safety was part and parcel with everything we did. We didnt have to measure itsafety was synonymous with our culture.

A safety department was a first for this company so the

CEO was eager to leverage his new asset. He was trying to

figure out how to present our safety-ness to potential clients as a way of separating us from our competitors. His

But that is specious reasoning. To borrow a quote from the

investment industry, Past performance is no guarantee of future gains. As I said before, there are many companies plying the skies who are accidents waiting to happenthey just havent experienced one yet. Conversely, there are operators doing things right but still experience losses.

Measuring how safe we really are is important. It is of great

benefit in making a business case. Its also important to determine whether our efforts at improving safety are

working. After all we cant manage what we cant measure. But lets first start with making sure everyone at Med-Trans is an active participant in our safety culture. When

employees agree to operate by a common set of ideals,

values and beliefs, synergy is created. Synergy is a very

powerful tool in creating a safety culture second to none.

Listed below are my thoughts on a common set of ideals to

ensure we achieve and maintain a strong safety culture:

1. We lead by example. We do the right thing. We

dont take shortcuts.

2. We dont accept unsafe behavior from ourselves or from our co-workers.

3. We dont punish employees for making honest errors, we correct them. We cant improve if we arent learning from our mistakes.

4. Continuous improvement is critical to our success.

We must be willing to actively seek ways to better

ourselves and our operation.

5. We dont make excuses for substandard performance. We acknowledge our shortcomings

and fix them.

6. Safety is not our business--its how we conduct our business.

7. If something isnt right we stop, assess and resolve it before resuming. We NEVER accept unnecessary

risks.

idea? Measure safety by the lack

of accidents. The more I thought

about it, the less convinced I was

that this was a good unit of

measurement. There are many

companies out there cutting

corners and breaking rules and

they havent had an accident, theyve just been lucky. Without knowing it, I think my boss was

really asking me: give me your

business case for being here. As I

soon learned, safety, just like

every other aspect of a business

must add value. Otherwise, it is a

distraction, robbing the company

of time, effort and resources.

On the surface, a company with an

accident free record has an

advantage over its competitors

who have suffered tragic losses.

APRIL 2013

One last thing. If youre a medical crewmember, remember its your butt in the aircraft too. If your pilot is doing a space shuttle entry when landing on scene or even at a hospital

for that matter, speak up. One day (or night) youll be glad you did.

From Hero to Zero in .25 Seconds

By Matt Harvey On the evening of 7 March, I made one of those mistakes

that after you do it you tell yourself, what the heck was I

doing? It was approaching shift change and the helicopter

had been staged outside for most of the day in preparation

for flights. Our hangar is a co-use hangar and the local FBO

tech had come down to move a private fixed winged aircraft

out of the hangar to conduct maintenance. It was at that

time I decided to move the helicopter in for the evening.

Temperatures were beginning to drop and it would facilitate

the on-coming pilot the ability to prefight in a heated and

well-lit environment.

The Med Crew were co-located with me and the plan was

that the nurse would operate the hangar door and the

paramedic would assist me in bringing the helicopter into

the hangar once the fixed winged aircraft was moved out of

the way. You think, sounds great, whats the issue. Well, this is about the point where I equate this to a guy who has

already moved the transporter out of the hangar and had

positioned it under the helicopter. The nurse was at the

hangar door control panel and the paramedic was helping

the FBO tech clear the fixed wing as it was pulled out as to

not have it contact our helicopter or the hangar. It was at

this point that I decided in order to save time I would, on my own, lift the helicopter and strap it down. This way, once

the fixed wing was out of the way, the paramedic and I could

move it inside. At this point you can probably see where this

is going and I should have seen it, as well.

From the front, the transporter appeared to be squarely

positioned under the helicopter and with the transporter in

the full down position a quick look from the starboard side

showed the right hand cradles to be lined up. So, if the right

is lined up, the left must be good, right? Wrong! What I

didnt notice is the fact that the transporter was not parallel under the helicopter, so while the right may have been lined

up, the left cradles were out of alignment to the aft. If I

would have checked both sides as well as raised the

(continued) .

A Timely Wire Reminder

By Don Savage

If youve been flying EMS for any length of time, Im sure you have a close encounter with wires story. In 1992, 40% of all civil helicopter accidents involved wire strikes

and while that percentage has dropped over the years,

EMS crews deal with this threat daily.

In the early days of Wings Air Rescue, one of our flight

nurses in a very calm voice told the pilot during a night

scene landing that she could see a set of wires out her

door. The pilot stopped the approach and hovering there

asked, how far. She responded, Im not sure but I could reach out and touch them. It turned out that this was the thin grounding wire that stretches across the tops

of high tension towers!

Again, years ago at Arizona Life Line a pilot made a perfect

approach into a night LZ. As he was shining his night sun

up to check for obstacles he noticed a wire was stretched

across the top of his turning rotor! He and the medcrew

never noticed it during the recon or landing.

So how do we avoid becoming a wire strike statistic? Pay

attention during the high reconnaissance. Most wires and

obstacles will be below 200 which means youre minimum recon altitude should be no lower than 300 day and 500 night. Are you too busy looking at the accident scene? That could mean youre missing Important safety information on your orbit or planned approach path.

Most importantly, fly your approach the way Med Trans

teachesSLOW and STEEP. Slow gives the pilot and crew time to see and avoid wires and Steep shortens the

obstacle zone. Are you looking for wires? Not necessarily.

Remember, its easier to find poles. When you see two poles, you know where the wires are!

During confined area training with new hires, I tell them

there are wires on the approach that are almost invisible.

Guess how they approach? Extremely slow and careful.

They sweep their light from side to side, up and down as

they creep inch by inch until they are down. When they

ask where the wires are, I say there arent any but they didnt know that. Just like EVERY off airport landing!

transporter up to just below the skids I would have picked

this up. My assumption was actually me accepting an unnecessary risk. In the composite risk management

process you are supposed to identify the hazard, access

the hazard, develop controls, implement controls,

supervise and evaluate. I failed at this on multiple levels.

As I rose the transporter and it took the weight of the

helicopter the sound of crunching fiberglass let me know

that I had just made a grievous error.

How can we keep this from happening again? Simple,

follow the standard (see read & initial memo dated 18 Mar

13), assume nothing, use your team, and double check.

Remember, it only takes one oh-crap moment to undo a

myriad of previous above average performance. So, what

can the Med-trans pilot reading this article take away from

this? In the wise words of my Father you can listen to me or you can learn the hard way. Unfortunately, in this case, I chose the hard way, but if you can learn from my mistake

and add it to your tool chest of items to be on guard for, it

can add a positive light to an otherwise negative situation.

Reporting Weather Incidents

By David Carr Which is better? Being on the ground wishing you were in

the air or in the air wishing you were on the ground?

Nothing is more important than making the right decisions--

especially when the decision is to discontinue a flight.

Weather is one of the greatest threats we face and we

need to treat it with the utmost of respect.

Heres a typical scenario most of us no doubt are familiar with: Everything starts out fine. The weather isnt CAVU, but its still okay to launch. So you strap on your flying machine and off you go, because after all, youre here to save lives and you cant do that from the La-Z-Boy. Then somewhere enroute, it gets a little darker overhead, and

grayer out front. Quietly you curse NOAA but tell the

medical crew that everything is fine. Soon, you find

yourself lowering the collective a little at first, then more.

APRIL 2013

When that doesnt work, your instinct tells you to slow down. The gray gets darker. Rain starts pelting the windscreen.

You slow down some more. Hopefully before your courage

isnt quite on E you spot a nice clearing down and to the right. As I said, hopefully. Some continue, betting that it will

get better just up ahead. They press on, descending and

slowing, squeezing the safety margin to almost zero. Some

find themselves staring at a white windscreen unprepared

for what to do next. What a bad position to put yourself in,

straining to see through bad visibility, youre low and getting lower, slow and getting slower when, poof, nothin but white?

We EXPECT you to discontinue a flight when it is inadvisable

to continue. Thats why we made you PIC. You have demonstrated the judgment and decision making ability to

know when to say when. Your first choice should be

controlled flight to suitable terrain of your choosing, but if

thats not possible, then making a command decision to transition from visual to instrument flight. Regardless of

which option you choose, there will be no quibbling or

second guessing your decision from the peanut gallery.

That is our 100% guarantee.

But when its all over, we need to know what didnt work so that we can make improvements to our operation. Thats where reporting comes in. Maybe youve been getting bad weather advice from your on-line resources. We need to

know that so we can help fix it. It may have been nothing

more than a long leg over an area of inadequate weather

reporting capability. Or maybe it is just weather dynamics

typical in your region. Well, if we have data that shows

weather aborts are common at your base, we can build that

knowledge into the training program for the crews, from new

hire training to devoting extra time on IIMC or unusual

attitude recovery.

Discontinuing a flight when you believe it is inadvisable to

safely continue is the right thing to do. After all, its better to be on the ground wishing you were in the air than the other

way around. You know what I meanweve all been there.

On March 12, the FAA accepted Med-Trans into their Safety Management System (SMS) Pilot project, joining numerous Commercial airlines and a few selected HEMS operators. This is an important step for our company. We have entered into cooperative relationship with our FAA Certificate Management Team (CMT) to develop and implement an SMS that will improve the safety of every facet of our company. One of the first changes you will see is a migration away from paper based reporting to a web based incident reporting system to report all safety related events, incidents or concerns, patient incidents and employee injuries. Expect updates on changes within the next few weeks.

The incident summaries provided here have been collected from around the industry and are shared for general awareness

purposes and in the interest of flight safety.

BH407

1st Quarter 2013

Human Error: 2

Environmental: 4

Material Failure: 2

Directed Laser: 0

EC-135

1st Quarter 2013

Human Error : 1

Environmental: 1

Material Failure: 1

Directed Laser: 1

The Med-Trans Safety Compass monthly newsletter

is one method we have of communicating with every

employee. We want this newsletter to be a forum for

fostering a culture of informing and learning.

I welcome your suggestions on topics you would like

to see addressed here. Better yet, send me your

article and I will get it added in the next issue.

Feel free to contact me by phone or email, my virtual

door is always open.

David Carr

Director of Safety

APRIL 2013

Maintenance On December 7, 2011, about 1630 Pacific standard time,

a Sundance Helicopters, Inc., Eurocopter AS350-B2

helicopter, N37SH, operating as a Twilight tour sightseeing trip, crashed in mountainous terrain about 14

miles east of Las Vegas, Nevada. The pilot and four passengers were killed, and the helicopter was destroyed

by impact forces and post-impact fire. The helicopter was

registered to and operated by Sundance as a scheduled

air tour flight under the provisions of 14 Code of Federal

Regulations (CFR) Part 135. Visual meteorological

conditions with good visibility and dusk light prevailed at

the time of the accident, and the flight operated under

visual flight rules.

The helicopter originated from Las Vegas McCarran

International Airport, Las Vegas, Nevada, about 1621 with

an intended route of flight to the Hoover Dam area and

return to the airport. The helicopter was not equipped, and

was not required to be equipped, with any on board

recording devices.

The National Transportation Safety Board determines the

probable cause(s) of this accident to be: Sundance

Helicopters inadequate maintenance of the helicopter, including:

1. The improper reuse of a degraded self-locking nut;

2. The improper or lack of installation of a split pin;

3. Inadequate post-maintenance inspections, which

resulted in the in-flight separation of the servo

control input rod from the fore/aft servo and

rendered the helicopter uncontrollable.

Contributing to the improper or lack of installation of the

split pin was the mechanics fatigue and the lack of clearly delineated maintenance task steps to follow. Contributing

to the inadequate post-maintenance inspection was the

inspectors fatigue and the lack of clearly delineated

inspection steps to follow.

Director of Safety David Carr David.carr@med-trans.net

The Med-Trans Leadership Team

Chief Operating Officer Rob Hamilton Hamiltonrobert@med-trans.net

Director of Operations Bert Levesque levesquebert@med-trans.net

VP, Program Operations Connie Eastlee Eastleeconnie@med-trans.net

Director of Maintenance Josh Brannon Brannonjoshua@med-trans.net

Chief Pilot Don Savage Savagedonald@med-trans.net

Assistant Chief Pilot Mike LaMee Lameemichael@med-trans.net

VP, Flight Operations Brian Foster Fosterbrian@med-trans.net

NTSB Chairwoman Deborah A.P. Hersman said, "This

investigation is a potent reminder that what happens in the

maintenance hangar is just as important for safety as what

happens in the air."